Anemia in Pregnancy

Prof. Vinita Das

HOD Ob/Gyn
KGMU Lucknow

Learning Objectives

Diagnose anemia in pregnancy

Learn the effect on mother & fetus
Learn S/S in pregnancy
Learn prevention of anemia
Learn supplementation of oral iron during pregnancy
Management of anemia during pregnancy
Labor & Delivery management
National anemia control program
Post partum contraception

Background Information
Commonest medical disorder in pregnancy
Prevalence in India varies between 50-70%
Prevalence in USA is 2-4%
Nutritional anemia (Fe deficiency) is commonest
It is important contributor to maternal & perinatal
morbidity & mortality as a direct or indirect cause

Definition - Anemia
A condition where circulating levels of Hb are
quantitatively or qualitatively lower than normal
Non pregnant women
Hb < 12gm%
Pregnant women (WHO)
Hb < 11 gm%
Haematocrit
< 33%
Pregnant women (CDC)
Hb <11 gm%
1st&3rd Trimester
2nd trimester
Hb < 10.5 gm%

ICMR Anemia Severity Classification

Hb values
Mild
Moderate
Severe
Very Severe

10.0-10.9 gm%
7-9.9
<7
<4

Causes of Anemia in Pregnancy

Nutritional / Iron deficiency anemia

Pre-pregnancy poor nutrition very important
Besides Iron, folate and B12 deficiency also important
Chronic blood loss due to parasitic infections Hookworm & malaria
Multiparity
Multiple pregnancy
Acute blood loss in APH, PPH
Recurrent infections (UTI) - anemia due to impaired erythropoiesis
Hemolytic anemia in PIH
Hemoglobinopathies like Thalassemia, sickle cell anemia
Aplastic anemia is rare

Patho-physiology of Nutritional Anemia in

Pregnancy
Augmented erythropoiesis in pregnancy
Blood volume increases 40-45% in pregnancy
Increase in plasma is more as compared to red cell mass
leading to hemodilution & decrease in Hb level
Iron stores are depleted with each pregnancy
Too soon & too many pregnancies result in higher
prevalence of iron deficiency anemia

Extra Iron Requirement & Loss During

Pregnancy

Due to cessation of menses & contraction of blood volume after delivery

conservation of iron is around 400 mg

Factors Required for Erythropoiesis

Proteins for synthesis of Globin
Mineral Iron for synthesis of heme
Hormones Erythropoietin (produced from Kidney, stimulates stem
cells in Bone Marrow), Thyroxine, Androgens
Trace elements Zinc (also important for protein synthesis &
Nucleic acid metabolism), Cobalt, Copper
Vitamins
Vit B12 required for synthesis of RNA in early stage,
Folic acid (Vitamin 9) required in later stage for DNA synthesis
Vitamin C necessary for conversion of folic acid to folinic acid, it
enhances absorption of iron from small intestine
Pyrodoxine B6 useful adjuvant in erythropoeisis
Vitamin A required for cell growth, differentiation & maintenance of
integrity of epithelium, immune function

Pharmaco-kinetics of Iron / daily requirement

Normal diet contain about 14
mg of iron
Absorption of iron is 5-10% (12 mg) & 3-4% in pure veg diet
Additional daily iron demand in
early pregnancy 2-3 mg/day
In late pregnancy 6-7 mg/day
So daily supplement of 40-60
mg of elemental iron is
required during pregnancy
Folic acid requirement is also
increased 400-600 ug/day
In strict veg Vit B 12 is also
deficient

Clinical Presentation
Depends on severity of anemia
High risk women adolescent, multiparous, multiple
pregnancy, lower socio economic status
Mild anemic - asymptomatic
Symptoms pallor, weakness, fatigue, dyspnoea,
palpitation, swelling over feet & body
Signs pallor, facial puffiness, raised JVP, tachycardia,
tachypnea, crepts in lung bases, hepato-splenomegaly,
pitting oedema over abdominal wall & legs
Haemic murmur, cardiac failure
Glossitis, stomatitis, chelosis, brittle hair

Effect of Anemia on Pregnancy & Mother

Higher incidence of pregnancy complications
PET, abruptio placentae, preterm labor
Predisposed to infections like UTI, puerperal sepsis
Increased risk to PPH
Subinvolution of uterus
Lactation failure
Maternal mortality due to
CHF,
Cerebral anoxia,
Sepsis,
Thrombo-embolism

Effect of Anemia on Fetus & Neonate

Higher incidence of abortions, preterm birth, IUGR
IUD
Low APGAR at birth
Neonate more susceptible for anemia & infections
Higher Perinatal morbidity & mortality
Anemic infant with cognitive & affective dysfunction

Most Critical Period

28-30 weeks of pregnancy
In labor
Immediately after delivery
Early Puerperium
CHF
(Failure to cope up with pregnancy induced
cardiac load)

Work Up of Pregnancy with Anemia

Detailed H/o age, parity, diet, chronic bleeding,
worm infestation, malaria, race etc

Examination
Pallor
Glossitis
Splenomegaly hemolytic anemia
Jaundice hemolytic anemia
Purpura bleeding disorder
Evidence of chronic disease Renal , TB
Anasarca & signs of cardiac failure in severe cases

Investigation
Severity of anemia Hb & Haematocrit, at first visit, 28-30
weeks & 36 weeks

Type of anemia GBP microcytic, macrocytic, dimorphic,

normocytic, hemolytic, pancytopenia

Bone marrow activity reticulocyte count (N .2-2%),

higher bone marrow activity is seen in
hemolytic anemia
following acute blood loss
iron def anemia on treatment

Cause of anemia by various investigations

GBP - Stained with Leishman stain

Normal smear Normocytic (Normal
size RBC), normochromic (Normal
colour RBC)
Iron deficiency Microcytic (small
RBC), hypochromic (pale RBC),
anisocytosis (variation in size),
poikilocytosis (variation in shape), with
or without target cells
Malarial parasites can be seen
Aplastic anemia shows low/no counts
Sickle cells can be demonstrated
Toxic granules can be seen
Abnormal Blast cells seen in Leukemia
Target cells in Thalassemia

Fe def anemia

Target cells Thalassemia

Blast cells

Toxic granules
Bone marrow
aplastic anemia

Malarial parasite

Red Cell Indices

RBC count decreases in anemia (N 3.2 million/cu mm)
PCV - < 32%, (N37-47%)
MCV low in Fe def anemia, microcytic
MCH - decreases
MCHC decreases, one of the most sensitive indices
(N26-30%)

Special Investigations
Serum Ferritin abnormal if < 20 ng/ml (N 40-160 ng/dl),
assess iron stores
Serum Iron N 65-165 ug/dl, decreases in Fe def
anemia
Serum Iron binding capacity 300-360 ug/dl, increases
with severity of anemia
Percentage saturation of transferrin 35-50%,
decreases to less than 20% in fe def anemia
RBC Protoporphyrin 30ug/dl, it doubles or triples in Fe
def anemia ( substrate to bind with Fe, can not be
converted into Hb in Fe def))

Differentiation between iron deficiency anemia & Thalassemia

9diminished synthesis of Hb b chains in Thalassemia)

Investigations Normal values

75-96 fl
MCV

Fe Def Anemia

reduced

Thalassemia
V reduced

MCH
MCHC
HbF
HbA2

27-33pg

reduced

V reduced

32-35 gm/dl

reduced

N or reduced

<2 %

normal

Raised

2-3%

N or reduced Raised >3.5%

Serum Iron

60-120 ug/dl

reduced

Normal

Serum Ferritin

15-300 ug/L reduced

300-350 ug/dl Raised

Normal
Normal

reduced
>50

Normal
Normal

TIBC
Bone iron stores
Free erythrocyte
protoporphyrin

<35 ug/dl

Other Investigations
Urine examination RBC & Casts
Stool examination occult blood, ova
Bone marrow examination refractory anemia
X-Ray chest Pulmonary TB
BUN/Serum creatinine Renal disease

Treatment for Iron Deficiency Anemia

Improving diet rich in iron &
fruits & leafy vegetables
Treat worm infections,
maintain general hygiene
Food fortification with iron &
genetic modification of food
Iron & folic acid
supplementation in young girls
& during pregnancy

Heme iron better, present in

animal food & is better
absorbed
Iron absorption enhanced by
citrous fruits, Vit C
Avoid tea, coffee, Ca,
phytates, phosphates,
oxalates, egg, cereals with iron

Iron Rich Foods

Green leafy vegetables-chana sag, sarson ka
sag, chauli. Sowa, salgam
Cereals - wheat, ragi, jowar, bajra
Pulses-sprouted pulses
Jaggery
Animal flesh food - meat, liver
Vit C - lemon, orange, guava, amla, green
mango etc.

Iron supplementation in Pregnancy

60 mg elemental iron & 400 ug of
folic acid daily during pregnancy
and 3 months there after
In anemia therapeutic doses are
180-200 mg /d
Route of administration depends
on, severity of anemia, Gest age,
compliance & tolerability of iron
Various preparations fumarate,
gluconate, succinate, sulfate,
ascorbate
Carbonyl iron better tolerated
Oral iron can have side effects like
nausea, vomiting, gastritis,
diarrhoea, constipation

Iron supplementation not

recommended in first
trimester
Higher incidence of
miscarriage
Birth defects
Bacterial infection (bacteria
grow after taking iron from
supplementation)

Oral Iron
Hb 8-11 gm%, early preg
Contraindication to Oral Iron
Therapy
Intolerance to oral iron
Severe anemia in advanced
pregnancy
Non compliant

Failure to Respond
Inaccurate diagnosis
Faulty absorption
Continuous blood loss
Co-existant infection
Concomitant folate deficiency

Indicators of response to
therapy
Feeling of well being
Improved look of patient
Better appetite
Rise in Hb .5-.7 gm/dl
per week (starts after 3
weeks)
Reticulocytosis in 7-10
days

Parenteral Iron Transfusion

Iron sucrose for parenteral use
Dose calculated - Wt in Kg x
iron deficit x 2.2 + 1000 mg for
iron stores
Response - by increase in Hb
level 1g/week
Increase in Reticulocyte count
with in 5-10 days
Clinical symptoms improve

Indications for Blood Transfusion

Severe anemia first seen after
36 weeks of pregnancy
Anemia due to acute blood
Loss APH & PPH
Associated Infection
Patient not responding to oral
or parenteral therapy
Anemic & symptomatic
pregnant women (dyspneic,
with heart failure etc)
irrespective of gestational age

Management of Labor
Labor should be supervised
Proper counseling & consent to be taken
Blood (whole & packed) kept cross matched
Women nursed in propped up position
Intermittent O2 to be given
Precaution to prevent infection & blood loss
Strict aseptic precautions & minimal P/V exams
Prophylactic antibiotic can be given
Patent iv line but fluids are avoided
In decompensated patient diuretic given

Second & Third Stage of Labor

Second stage cut short by forceps or ventouse
Active management of 3rd stage of labour to be done
Oxytocics, P/R misoprostol can be given after delivery of
fetus
Injection methergin iv contraindicated
Even normal blood loss may be tolerated poorly in
anemic patient
IV Frusemide given after delivery to decrease cardiac
load

Post Natal Care & Contraception

Early ambulation is encouraged
Hematinics are continued for 3-6 months
Watch for subinvolution , puerperal sepsis, CHF,
thrombo-embolism & lactation failure
Avoid pregnancy at least for 2 years
LAM, barrier contraception, POP after 3 weeks, IUCD or
permanent sterilization

Pregnant woman is considered anemic when her Hb is

below (unit gm/dl)

A. 12
B. 11
C. 10
D. 9

Most common cause of anemia in pregnancy in

India is

A. Nutritional anemia
B. Parasitic anemia
C. Aplastic anemia
D. Thalassemia

Iron deficiency anemia can be diagnosed earliest

by which laboratory test

A. Hb%
B. Serum ferritin
C. Serum iron
D. RBC protoporphyrin

Response to anemia management by oral Fe

therapy in pregnancy can be assessed earliest by

A. Increase in Hb%
B. Increase in reticulocyte count
C. GBP
D. Increase in S ferritin

Which complication is not common in Pregnancy

with anemia

A. PIH
B. Preterm labour
C. GDM
D. Puerperal sepsis